Bloomington, IL Nursing Home Ratings

If your parent, grandparent or spouses has suffered from a facility acquired bedsore in McLean County, Illinois it is imperative to take immediate action to ensure their health and well-being. The Bloomington nursing home neglect attorneys at Rosenfeld Injury Lawyers LLC have handled many cases where the neglectful actions of nursing staff manifested debilitating pressure sores, bedsores, decubitus ulcers and pressure ulcers.

Every resident in an Illinois nursing facility is at risk of developing bedsores, especially those who are bedridden or bound to a wheelchair. Nearly every bedsore can be prevented, so the damaging effects of developing a wound should never be taken lightly. If the wound is left untreated, the resident can develop serious medical conditions including osteomyelitis (bone infection), sepsis (blood infection), gangrene or death. In many situations, the only resolution to stop the damaging effects of a bedsore is amputation.

The number of cases involving facility acquired pressure ulcers has risen dramatically in the last few decades. This is because the aging population continues to expand as many members of the baby boomer generation have reached 65 years or older. With nearly 79,000 residents living within the Bloomington city limits, more than 11,000 are senior citizens, many of whom live in nursing facilities throughout the community. Many of the problems associated with facility acquired bedsores are the result of overcrowded conditions or lack of qualified nursing staff that can provide ample and appropriate care to every resident.

Bloomington Nursing Home Resident Bedsore Concerns

Before placing a loved one in a nursing facility, it is essential to understand that you have many options. Not every nursing home throughout McLean County offers the same level of service. In fact, national databases including Medicare.gov continuously update their information detailing specifics on opened investigations, filed complaints, safety violations and health problems. Our Illinois elder abuse lawyers continuously review this information and post our findings on this website in an effort to provide families information they need to determine the ideal location to place their loved one who requires the best care.

Comparing Bloomington Area Nursing Facilities with Respect to Pressure Sores

Failure to Follow Protocols for Treating Pressure Ulcers that Resulted in a Degrading Wound

In a summary statement of deficiencies dated 04/22/2015, a complaint investigation against the facility was opened for its failure to “identify pressure sores, monitor pressure sores and provide treatment.” In addition, the deficient practice by the nursing staff at Bloomington Rehabilitation and Healthcare Center resulted in the resident “developing a stage III pressure ulcer to the coccyx, an unstageable pressure ulcer to the right buttock and deterioration of a right heel unstageable pressure ulcer.”

The complaint investigation involved a review of the resident’s 03/12/2015 H & P (History and Physical) report that documents the resident “has a decubitus ulcer [bedsore] on the right heel and right gluteal region.” The resident’s 03/19/2015 Hospital Discharge Summary documents of the resident “had an appointment for an office visit with [the resident’s primary care physician] on 04/01/2015 at 1:40 PM.”

The state investigator reviewed the resident’s MDS (Minimum Data Set) revealing that the resident “requires total assistance with bed mobility, toilet use and bathing […and that the resident] is at risk for pressure ulcers and does not have a pressure ulcer.” However, contradicting Nursing Admission Assessment report documents of the resident “has a pressure area to the right heel that measures 7.0 centimeters by 6.5 centimeters and [that the resident’s] bottom is red.”

The investigator noted that the resident’s 03/19/2015 TAR (Treatment Administration Record) is blank. The subsequent 04/01/2015 TAR (Treatment Administration Record) “documents a treatment order for [the resident] to have daily skin checks.” However, the TAR (Treatment Administration Record) throughout the month of April “contains no documentation of skin checks being completed [from 04/02/2015 through 04/05/2015 and from 04/10/2015 through 04/12/2015].” The investigator also knows that the resident’s TARs (Treatment Administration Records) for “March 2015 and April 2015 do not contain wound measurements.”

The complaint investigation was initiated at 11:25 AM on 04/13/2015 when the resident “stated that her right foot causes her pain […and] that she has a sore on her right front and a sore on her bottom […and] that she tries to take care of it on her own and that her brother sent her some cream from Alaska to put on these areas to help make them better.” The resident also stated that “no one in the facility has provided treatment to her foot or bottom.”

At that time, the facility’s Licensed Practical Nurse assessed the resident’s buttocks and heels. During that assessment, the resident’s “incontinence brief was removed and [the resident’s] buttocks did not have a dressing.” The resident “was noted to have a pressure sore on the right buttock measuring 0.5 centimeters by 1.0 centimeters.”

During the assessment, “the pressure sore to the coccyx was ready contained 50 percent yellow slough. An unstageable pressure sore was observed to the right heel which measured 7.0 centimeters by 8.7 centimeters. The right heel pressure sore was 100 percent necrotic and covered [the resident’s] heel.” The nurse providing care stated “she was unaware of the areas and that [the resident] did not have treatment orders for these areas. At that time, the [Certified Nurse’s Assistant/Social Service Director] stated that she helps on the floor a lot and that [the resident] has had the areas since admission.”

An interview was conducted by the investigator with the facility’s Director of Nursing at 12:10 PM on 04/13/2015 who stated: “that she does not measure wounds weekly […and] that the floor nurses do the weekly measurements.” The Director of Nurses confirmed that the resident “had no treatment orders and that the daily skin checks contained black […and] that pressure sore measurements would be documented in the nursing notes are on the TAR (Treatment Administration Record).”

During the interview the Director of Nurses also “confirmed that there were no weekly measurements on the TAR or nursing notes for [the resident’s] pressure sores […and that this practice] is unacceptable documentation.”

The following day at 1:05 PM on 04/14/2015, the investigator conducted an interview with the facility’s Transport Aide who stated: “that she transported [the resident to the Primary Care Physician’s] office on 04/01/2015.” However, the Aide stated that the resident “was not seen by the [primary physician] because the appointment had been canceled […and] that she did not reschedule [the resident’s] appointment because the Administrator schedules all the resident’s appointments.”

The Transport Aide confirmed that she “did not inform [the Administrator that the resident’s] appointment had been canceled […and] that she told the resident’s nurse but could not remember which nurse [stating] that the resident did not have another appointment scheduled to see [their primary care physician].”

Our Bloomington nursing home neglect attorneys recognize a failing to follow procedures and protocols when providing treatment to residents suffering from pressure ulcers could cause additional harm if the bedsore degrades to a life-threatening condition. The deficient practice by the nursing staff at Bloomington Rehabilitation and Healthcare Center might be considered negligence or mistreatment because their actions fail to follow the facility’s May 2007 policy title: Decubitus Care/Pressure Areas Policy that reads in part:

“Upon notification of skin breakdown the pressure area will be assessed and documented on the TAR (Treatment Administration Record). Document size, stage, site, depth, drainage, color, odor and treatment. Notify the physician for treatment orders. Documentation of the pressure area must occur upon identification and at least once a week on the TAR (Treatment Administration Record).”

In a summary statement of deficiencies dated 08/20/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “reposition [the resident’s body] in a timely manner.” The deficient practice by the nursing staff at Heartland of Normal affected two residents at the facility.”

The deficient practice was noted by the state surveyor after review of a resident’s records including the facility’s Decubitus Ulcer List the documents of the resident “was admitted to the facility with a Stage IV ulcer (bedsore) to his coccyx.”

The investigator also reviewed the resident’s 05/27/2015 MDS (Minimum Data Set) that documents that “the resident requires the total assistance of two for turning and repositioning.”

In addition, the resident’s 03/26/2015 Care Plan documents an Unstageable Pressure Ulcer to Coccyx related to impaired mobility and incontinence. Encourage and assist as needed to turn and reposition, use assistive devices as needed.”

The resident’s Predicting Pressure Sore Risk Assessment indicates that the resident “is at high risk for skin breakdown. No other pressure sore risk assessments were in [the resident’s] medical record.”

The state investigator observed the resident at 9:45 AM on 08/17/2015 who was “sitting up in his wheelchair in his room.” The Director of Care Delivery “stated that is his daughter with him, either she or [his wife] is here a lot.

Later that afternoon, 1:35 PM the Certified Nursing Assistant stated “we are going to lay him down. He has been up in the wheelchair since we got him up this morning at around 9:30 AM – 10:00 AM. The nurse came in and did cares for him but that is it.”

The Director of Care Delivery confirmed that the Licensed Practical Nurse “came in and gave him his medications but no staff had been into reposition him since he had gotten up into the wheelchair and stated, ‘They don’t do anything with him while up in the chair’.”

That same afternoon at 1:40 PM on 08/17/2015, two Certified Nursing Assistants transfered the resident “from his wheelchair into bed via a mechanical lift.” The resident “had a dressing on his coccyx dated [that day, and] also had an uncovered open area to his left hip.” One Certified Nursing Assistant stated, “that is not new, they know about it, he had it on Saturday [08/15/2015], and the [Licensed Practical Nurse] said that the Wound Nurse would have to come in and look at it before anything could be done with it.”

However, when the state surveyor interviewed the facility’s Assistant Director of Nursing at 2:10 PM on that day, the Director stated, “I was not aware that [the resident] had a new open area. They should have called the doctor to get a treatment order since I wasn’t here.” Later that afternoon at 4:00 PM, the Assistant Director of Nursing stated, “Anybody with breakdown needs to be turned and repositioned at least every two hours.”

Our Normal nursing home neglect attorneys recognize that failing to provide all the necessary services and proper treatment to a resident suffering with the degrading bedsore could place their health and well-being in jeopardy. The deficient practice by the nursing staff at Heartland of Normal might be considered negligence or mistreatment because their actions fail to follow the facility’s 2013 policy title: Alteration in Skin Integrity Policy that reads in part:

In a summary statement of deficiencies dated 07/09/2015, a notation was made during an annual licensure and certification survey by a state investigator concerning the facility’s failure to “maintain a dressing over pressure ulcer [and a failure] to give timely incontinence care for one resident [at the facility].”

The deficient practice was noted by the state investigator who reviewed the facility’s 07/06/2015 and 07/07/2015 Wound History Screen that documents “there are two pressure sores on the left Ischium (lower back part of the hip bone) [of the resident].” The 07/06/2015 pressure sore report documents its location as the Ischium left-distal and measures 1.0 centimeters by 0.4 centimeters by 0.1 centimeters. The report on the following day 07/07/2015 documents the location of the Ischium left measuring 1.5 centimeters by 2.0 centimeters by 0.1 centimeters.”

The state surveyor noted that the resident’s Braden Scale for Predicting Pressure Sore Risk documents that the resident has “a risk score of 13” indicating moderate risk for developing pressure sores.

Documentation reveals at 1:52 PM on 07/06/2015, a Certified Nursing Assistant providing the resident care change the resident’s “incontinent brief and upon removing [the resident’s] clothing, the slacks were wet in the back and the brief was saturated with urine. There is no dressing over the pressure ulcers.”

Minutes later at 2:05 PM, the facility’s Wound Nurse “prepared to do a dressing change for [the resident].” At that time, the Wound Nurse “pulled the blanket off of [the resident] and exposed her bottom. There was no dressing on either pressure ulcer.” The Wound Nurse “verify there was no dressing and there should have been addressing on the pressure ulcers.”

That same afternoon at 2:20 PM, the Certified Nurses’ Assistant stated, “I am the CNA for today and I did not get [the resident] up this morning, the night shift did […and] this was the first time today that I have changed [the resident] and there was no dressing in the brief, the night shift must have taken it off.”

Our Normal elder abuse lawyers recognize that failing to follow protocols, procedures and policies when providing care and treatment to allow an existing bedsore to heal could place the health and well-being of the resident in jeopardy. The deficient practice by the nursing staff at McLean County Nursing Home might be considered negligence or mistreatment because their actions failed to follow the facility’s undated policy title: McLean County Nursing Home Wound and Ulcer Policy and Procedure that reads in part:

“Total Braden Scale for Predicting Pressure Sore Risk score 13-14 skin will be gently cleansed at the time of soiling with soap and water, or commercially available perineal cleanser.”

Failure to Follow Repositioning Protocols for Treating Pressure Ulcers that Resulted in a Degrading Wound

In a summary statement of deficiencies dated 07/02/2015, a complaint investigation against the facility was opened for its failure to “reposition [a resident at the facility] reviewed for positioning.”

Part of the complaint investigation involved a review of a resident’s 05/11/2015 MDS (Minimum Data Set) revealing the resident “is non-ambulatory, requires the extensive assist of two for transfers and bed mobility and is frequently incontinent of stool and occasional incontinent of urine.”

Additional documents reviewed by the state investigator included the resident’s 05/25/2015 Care Plan the documents, “I am at risk for skin breakdown related to being dependent on staff for bed mobility. Please reposition me at least four times per shift and more often if necessary to maintain adequate circulation all pressure points.”

The state investigator noted that the resident’s Braden Scale for Predicting Pressure Sore Risk of 05/21/2015 and 06/26/2015 document that the resident “is at risk to develop pressure ulcers.”

An observation made of the resident on 06/30/2015 continuously observe the resident “lying in bed from 11:30 AM through 2:05 PM, without being repositioned.”

During a 1:40 PM 06/30/2015 interview with the Certified Nursing Assistant (CNA), the CNA stated “I assisted [the primary Certified Nursing Assistant with the resident’s] cares, around 6:00 AM and again at 10:30 AM. We rolled her at that time.” A subsequent interview with the CNA at 1:49 AM on 06/30/2015 documented that the CNA stated, “the resident is in my group of residents to care for. I did cares including repositioning her today a little before 6:00 AM and sometime before 11:00 AM. I’m going to do her soon because she is overdue.”

Our Chenoa nursing home neglect attorneys recognize that failing to provide care and repositioning according to protocols when caring in treating a resident suffering from bedsores could place their health and well-being in jeopardy. The deficient practice by the nursing staff at Meadows Mennonite Home might be considered negligence or mistreatment because their actions fail to follow established procedures and protocols enforced by state and federal nursing home regulators.

In a summary statement of deficiencies dated 06/03/2015, a complaint investigation was opened against the facility for its failure to “assess, treat and monitor skin breakdown.” The deficient practice by the nursing staff at Morton Villa Health and Rehabilitation Center directly affected one resident at the facility.

A complaint investigation started with a review of a resident’s MDS (Minimum Data Set) records dated 01/27/2015 and 04/01/2015 the documents of the resident “is at high risk for developing pressure ulcers, has a history of Stage III pressure ulcers in January 2015, requires total assistance for transfers and bed mobility and is unable to ambulate.

The state investigator also noted that at 9:15 AM, 06/01/2015 the resident “was escorted, in the wheelchair, to the nurses’ station by staff [where the resident] remained at the nurses station until escorted to [their] room at 9:38 AM.” At that time, the resident “remained in [their] wheelchair just inside [their] room until 10:20 AM.”

Approximately 10 minutes later at 10:40 AM, the Certified Nurses’ Aide providing the resident care stated that the resident “has been in a wheelchair since approximately 7:00 AM […and] is to be turned and repositioned every two hours as needed.”

A few minutes earlier at 10:30 AM on 06/01/2015, the Certified Nursing Assistant stated that the resident “was readmitted from the hospital with an open area to the coccyx […and that the resident] is totally dependent on staff for cares and is usually non-verbal.” The Certified Nursing Assistant stated “no knowledge of treatment to [the resident’s] buttock/coccyx area […and verified that the resident] does not have any type of treatment in place at this time.”

The investigator reviewed the resident’s 05/19/2015 Hospital Progress Note the documents of the resident “was admitted to the hospital with a suspected deep tissue injury 0.8 centimeters, healing midline slip and coccyx with a pink blanchable area to the coccyx.”

A review of the resident’s May 2015 TAR (Treatment Administration Record) documents physician’s orders but “does not document daily skin checks were completed” on numerous days throughout the month. In addition, upon readmission to the facility on 05/23/2015, the resident’s TAR (Treatment Administration Record) does not document skin checks were completed on numerous days including 05/23/2015, 05/25/2015, 05/27/2015, 05/29/2015 and 05/30/2015.” The resident TAR (Treatment Administration Record) also “does not document any type of treatment to the [resident’s] buttock/coccyx area.”

The investigator then reviewed the facility’s re-Admission Nursing Assessment that did not reveal any documented evidence of any skin breakdown. The resident’s 05/06/2015 through 05/29/2015 Nurses Notes “do not document any skin breakdown” nor does the Weekly Pressure Sore Logs for the weeks of 05/04/2015, 05/11/2015, 05/18/2015 and 05/26/2015.

A review of the resident’s 05/24/2015 Initial Hospice Plan of Care documents of the resident “had a 0.8 centimeter pressure area on the sacrum with no treatment orders noted.”

The state investigator interviewed the facility’s Wound Nurse at 11:15 AM on 06/02/2015 who stated that the resident’s “red gluteal fold should be treated with a barrier cream that contains zinc.” The Wound Nurse also stated, “I was not aware of [the resident’s] skin breakdown until [the previous day] 06/01/2015 […and] stated the nurses should have filled out a non-pressure ulcer sheet on re-admission and given me a copy so I was aware.”

The Wound Nurse also stated that the resident “had a history of Stage III pressure ulcer in January 2015 and is at high risk for skin breakdown.” The nurse also verified that the resident’s “redness to the gluteal fold has not been assessed or treated since [the resident] was it made it [to the facility, and stated that the resident] has no open areas at this time.” However, the Wound Nurse also verified that the resident “should be turned a minimum of every two hours.”

Our Morton nursing home neglect attorneys recognize that failing to follow protocols when providing care and treatment to resident suffering with pressure ulcers could place their health and well-being in immediate jeopardy. The deficient practice of the nursing staff at Morton Villa Health and Rehabilitation Center might be considered mistreatment or negligence because their actions fail to follow the facility’s October 2010 policy titled: Prevention of Pressure Ulcers Policy that reads in part:

“Residents with a risk factor for skin breakdown related to moisture should have a barrier cream ordered and applied and placed on a minimum of every two-hour check and change program residents who are immobile and chair-fast should change position at least every one hour. The history of a healed pressure ulcer and its stage is important since areas of healed Stage III and Stage IV pressure ulcers are more likely to have a recurrent breakdown. Any change in the condition of the resident’s skin should be recorded in the resident’s medical record.”

The Underlying Causes of Pressure Ulcers and Infections

Many residents in nursing facilities are highly dependent on the home’s nursing staff to assist them in daily functions. Mobility challenged residents are the most highly dependent on staff members and extremely vulnerable to any negligence or mistreatment. The staff is required to monitor their resident’s movement or lack of movement and adjust their body position at least one time every two hours or less to ensure that no part of the body restricts blood flow to the skin and underlying tissue in specific bony parts including the ankles, heels, toes, buttocks, hips, sacrum, shoulders, shoulder blades, back of the head and elbows.

If the staff in a nursing facility is inattentive to all of the needs and requirements of sedentary residents, serious life-threatening complications can quickly arise. Residents at the facility who are confined to stay in their beds for extensive periods of time must be routinely turned in an effort to prevent the development of a bedsore. Even at the early stages of developing pressure ulcer, the open wound can be extremely painful and highly susceptible to infection. However, once the sores are detected, and proper treatment is provided the chances of serious life-threatening changes is highly diminished.

Unfortunately, many of the nursing staff at facilities all across Illinois are inadequately trained to detect bedsores in the early stages. That is why so many nursing home residents throughout the Bloomington area suffer serious complications including infection, gangrene and amputation caused by a lack of effective treatment for the open wound. In addition, residents that have a compromised immune system are highly susceptible to life-threatening blood infection (sepsis) and bone infection (osteomyelitis).

Chronic diseases including hardening of the arteries and diabetes mellitus make it significantly more challenging to heal a pressure ulcer due to the already restrictive blood flow circulation caused by these conditions. However, numerous preventative measures are available to protect the resident against developing sores including routine turning, the use of devices including air cushions and air beds and frequent examination and assessment of the resident’s skin to identify a bedsore in its early stage.

Because nearly every pressure sore can be prevented or avoided, the development of any open wound caused by constricted blood flow might be an indicator of subpar care being provided by the nursing home. Family members who suspect a loved one is the victim of negligence that resulted in a bedsore often contact a personal injury attorney who specializes in nursing home abuse bedsore cases.

Hiring a Lawyer to Prosecute a Bloomington Pressure Sore Lawsuit

If your loved one has developed a pressure ulcer, it is essential to immediately alert the attending nurse, caregiver, nurse practitioner or administrator at the facility. This is because the pressure must be relieved to the area using repositioning, or devices including sheepskin, special foam cushions and pillows. The nursing staff must take every precaution to avoid further injury caused by shearing or friction.

The doctor will likely encourage the resident to begin eating healthier foods and direct the nursing staff to cleanse the ulcer using proven methods to halt its development and prevent damage to the skin and underlying tissue. The best possible action to take while at the facility is to contact the nursing staff to inform that you are serving as an advocate on behalf of your loved one.

The Bloomington nursing home abuse attorneys at Rosenfeld Injury Lawyers LLC specialize in cases involving geriatric bedsore litigation. We carefully evaluate every circumstance involved in our client’s case and will provide a variety of legal options after an initial consultation. We make every effort possible to ensure that your loved one receives the proper care and attention. If our law firm determines negligence or mistreatment was involved, we fight aggressively to ensure that you and your loved one receive the fair and just compensation you deserve.

We encourage you to contact our law offices today at (800) 926-7565 to schedule a free case evaluation. Every bedsore nursing home abuse case we accept is handled through contingency fee arrangements. This means you and your loved one receive immediate legal representation without any upfront payment.

Should you have questions about Illinois law related to pressure sores, view our page here.

Jonathan did a great job helping my family navigate through a lengthy lawsuit involving my grandmother's death in a nursing home. Through every step of the case, Jonathan kept my family informed of the progression of the case. Although our case eventually settled at a mediation, I really was impressed at how well prepared Jonathan was to take the case to trial. Lisa

★★★★★

After I read Jonathan’s Nursing Home Blog, I decided to hire him to look into my wife’s treatment at a local nursing home. Jonathan did a great job explaining the process and the laws that apply to nursing homes. I immediately felt at ease and was glad to have him on my side. Though the lawsuit process was at times frustrating, Jonathan reassured me, particularly at my deposition. I really felt like Jonathan cared about my wife’s best interests, and I think that came across to the lawyers for the nursing home. Eric